Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Screening for abdominal aortic aneurysm
- Hisato Takagi, Norikazu Kawai and Takuya Umemoto (13 October 2007)
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Letter concerning the editorial on the Cochrane review of screening for abdominal aortic aneurysms
- Jes S. Lindholt (15 October 2007)
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screening for AAA
- Tien L Luk, Anthony S Ward (26 October 2007)
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Screening for abdominal aortic aneurysm will save lives
- Jonothan J Earnshaw, George Hamilton (5 November 2007)
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Hisato Takagi, Consultant cardiovascular surgeon Shizuoka Medical Centre, Shizuoka 411-8611, Japan, Norikazu Kawai and Takuya Umemoto
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In their Editorials, Greenhalgh and Powell(1) cited a recent Cochrane review(2) which reported that screening asymptomatic people for abdominal aortic aneurysm (AAA) significantly reduced not all-cause but AAA-related mortality in men aged 65-79 years. The review,(2) however, excluded the more recent over 15-year follow-up in the Chichester study,(3) median 9.6-year follow- up in the Viborg Country study,(4) and mean 7.1-year follow-up in the Multicentre Aneurysm Screening Study (MASS).(5) Therefore, we(6) performed a meta-analysis of currently available longest follow-up results (both AAA - related and all-cause mortality) of randomized controlled studies of screening for AAA in men. Our comprehensive search identified four reports: the Chichester study (over 15-year follow-up),(3) the Viborg Country study (median 9.6-year follow- up), (4) the Western Australia study (median 3.6-year follow-up),(7) and the MASS (mean 7.1-year follow-up).(5) Pooled analysis of the four reports demonstrated a statistically significant reduction in both AAA-related (risk difference, |0.25%; 95% CI, |0.46% to |0.04%) and all-cause (risk difference, | 1.06%; 95% CI, |1.81% to |0.31%) mortality with screening relative to control in a random-effects model.(6) In conclusion, our meta-analysis,(6) an update of the Cochrane review,(2) demonstrated that screening for AAA significantly reduced not merely AAA- related but also all-cause mortality in men aged 65 years. 1 Greenhalgh R, Powell J. Screening for abdominal aortic aneurysm. BMJ 2007; 335:732-3. 2 Cosford PA, Leng GC. Screening for abdominal aortic aneurysm. Cochrane Database Syst Rev 2007;(2):CD002945. 3 Ashton HA, Gao L, Kim LG, Druce PS, Thompson SG, Scott RA. Fifteen - year follow-up of a randomized clinical trial of ultrasonographic screening for abdominal aortic aneurysms. Br J Surg 2007;94:696-701. 4 Lindholt JS, Juul S, Fasting H, Henneberg EW. Preliminary ten year results from a randomised single centre mass screening trial for abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 2006;32:608-14. 5 Kim LG, P Scott RA, Ashton HA, Thompson SG; Multicentre Aneurysm Screening Study Group. A sustained mortality benefit from screening for abdominal aortic aneurysm. Ann Intern Med 2007;146:699-706. 6 Takagi H, Tanabashi T, Kawai N, Umemoto T. Screening for abdominal aortic aneurysm reduces both aneurysm-related and all-cause mortality. J Vasc Surg (in press). 7 Norman PE, Jamrozik K, Lawrence-Brown MM, Le MT, Spencer CA, Tuohy RJ, et al. Population based randomised controlled trial on impact of screening on mortality from abdominal aortic aneurysm. BMJ 2004;329:1259. Competing interests: None declared |
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Jes S. Lindholt, Senior Researcher Viborg Hospital, 8800 Viborg
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In the BMJ editorial, Prof. Greenhalgh and Prof. Powell commented a recent Cochrane review on screening for abdominal aortic aneurysms (AAA)(1). Some critical comments on the quality of this Cochrane review seem to be justified. The cut-of date of the review is reported to be January 2007. However, concerning the Viborg Study, the Cochrane reviewers claim that the randomisation method is not stated, that causes of death outside hospitals and overall mortality is not reported. This would be true if only a preliminary report from 2002 was included(2), but the topics are fully covered in a BMJ publication of the major findings from 2005(3). The reviewers claim to have included this paper, but do not use the findings at all. The data in this BMJ publication were used to perform a cost effectiveness analysis after five years published in 2006(4), which is much more robust and relevant to compare with findings in the MASS trial, in stead of the used complete, long term estimation suggested in the preliminary report(2). Apparently, the reviewers never identified this paper because it is neither included nor excluded. The costs per gained living year after 5 years were 6090 without including post discharge costs, discounting or quality of life adjustment. However due to less screening costs because of the hospital based setting, and better benefits concerning reduction in AAA-mortality and emergency operations, the cost effectiveness in the Viborg Study must be expected to be stronger than the MASS trial. Finally, long term results from the Viborg Study(5) were published in 2006, but apparently it was not identified by the reviewers because it is neither included nr excluded. It also reports data on operative complications as the Cochrane reviewers would like to see reported. So in all, I strongly agree with Prof. Greenhalgh and Prof. Powell, that an up date is needed but it ought to include all relevant published randomised data on benefits and costs of screening for AAA published after 2004 in order to be at the usual high quality level of Cochrane reviews. 1. Greenhalgh R, Powell J. Screening for abdominal aortic aneurysm. BMJ 2007;335:732-733, 2.Lindholt JS, Juul S, Fasting H, Henneberg EW. Hospital costs and benefits of screening for abdominal aortic aneurysms. Results from a randomised population screening trial. Eur J Vasc Endovasc Surg. 2002 Jan;23(1):55-60. 3. Lindholt JS, Juul S, Fasting H, Henneberg EW. Screening for abdominal aortic aneurysms: single centre randomised controlled trial. BMJ. 2005 Apr 2;330(7494):750. Epub 2005 Mar 9. 4. Lindholt JS, Juul S, Fasting H, Henneberg EW. Cost-effectiveness analysis of screening for abdominal aortic aneurysms based on five year results from a randomised hospital based mass screening trial. Eur J Vasc Endovasc Surg. 2006 Jul;32(1):9-15. Epub 2006 Apr 17. 5. Lindholt JS, Juul S, Fasting H, Henneberg EW. Preliminary ten year results from a randomised single centre mass screening trial for abdominal aortic aneurysm. Eur J Vasc Endovasc Surg. 2006 Dec;32(6):608- 14. Epub 2006 Aug 8. Jes S. Lindholt, Ph.D. Vascular Research Unit Viborg Hospital Denmark Competing interests: None declared |
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Tien L Luk, SpR surgery basingstoke and north hampshire nhs foundation trust, Aldermaston Road, Basingstoke RG24 9NA, Anthony S Ward
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Greenhalgh and Powell (BMJ 13 10 07) state that the general threshold aortic diameter for intervention is > 5.5cm. Two patients with 5.3cm and 5.2cm aortic aneurysms were recently admitted with rupture at our hospital. In both cases the aortic diameter was measured by an experienced sonographer two months prior to emergency admission. CT at the time of rupture confirmed the ultrasound measurements. Neither patient had exhibited any precipitating factors for aneurysmal rupture. Aneurysms of < 5.5cm diameter have been treated successfully by endovascular intervention (1) and it is possible that the threshold for open repair should also be revised downwards. This may particularly apply to women who have smaller aortic diameters than men.(2) 1. Zarins CK, Crabtree T, Arko FR, Heikkinen MA, Bloch DA, Ouriel K, White RA. Endovascular repair or surveillance of patients with small AAA. Eur J Vasc Endovasc Surg. 2005; 29(5):496-503 2. Harthun NL, Cheanvechai V, Graham LM, Freischlag JA, Gahtan V.Prevalence of abdominal aortic aneurysm and repair outcomes on the basis of patient sex: Should the timing of intervention be the same? J Thorac Cardiovasc Surg. 2004 Feb;127(2):325-8. Competing interests: None declared |
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Jonothan J Earnshaw, Consultant Surgeon Gloucestershire Royal Hospital, George Hamilton
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Sir, The Cochrane review recently highlighted in BMJ (2007; 334:1077) and the letter from Takagi et al (BMJ 2007; 335: 899) describing the reduction in all cause mortality in men, merely adds weight to a scientific case for aneurysm screening that has been undisputed for several years. A working party attached to the National Screening Committee (NSC) has assembled a Standard Operating Procedure for a National Aneurysm Screening Programme for men aged 65 years. Vascular specialists in the UK are enthusiastic and raring to go. Yet the Department of Health is strangely silent about the Programme and the possibilities for funding. Greenhalgh and Powell (BMJ 2007; 335: 732-3) articulate the doubts of some politicians concerning the quality of elective aneurysm surgery in the UK (mortality rates in most hospitals are 6%, but may be as high as 10% in some areas). There are also concerns about the ability to provide sufficient information to enable the men to make an informed choice before accepting the screening ultrasound test. The Vascular Society of Great Britain and Ireland has signed up to a quality assurance programme through our National Vascular Database and governance procedures, and also to a continuous quality improvement programme. Much work has already been done to provide men with the information they need in a variety of different formats. It is now time for the Department to make a statement about funding the Programme. The current suggestion is that Specialist Commissioners and Strategic Health Authorities should prioritise aneurysm screening according to local needs. This will lead to piecemeal provision and continuation of the abhorrent postcode lottery, and also risks the development of non standard programmes of suspect quality. It is time for all doctors who have 65 year old male relatives to remind politicians that aneurysm screening will prevent approximately 50% of all deaths from the condition, that is almost 3000 lives per year the same as breast cancer screening, but for half the cost. Yours faithfully Jonothan J Earnshaw, Hon Secretary
The Vascular Society of Great Britain and Ireland 35/43 Lincolns Inn Fields, London WC Competing interests: None declared |
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